Robotic surgery comes to prostate removal

June 25, 2003

Surgeons at the University of Chicago Hospitals are using a robotic system to remove cancerous prostate glands with less pain, smaller scars, minimal blood loss and rapid recovery.

Patients treated using the da Vinci robotic system leave the operating room with four quarter- to half-inch holes in the belly, and a one-inch incision for specimen removal, instead of the standard six-inch incision from the navel to the pelvic bone. Patients often go home the next day and resume normal activities within a week, compared to nearly six weeks after open surgery.

Although laparoscopic--or 'minimally invasive'--surgery has been around for more than a decade, "the first U.S. surgeons that applied this approach to prostate cancer found it too difficult and complex," said Arieh Shalhav, M.D., associate professor or surgery and a specialist in laparoscopic surgery.

These surgeons worried that without the clear access and tactile feedback of open surgery, they might miss cancerous tissue or damage the tiny nerve bundles that cross over the surface of the prostate, resulting in impotence.

A few years ago, however, a group of French surgeons began to explore minimally invasive surgery for the prostate and to develop the necessary techniques.

"The results from the leading groups are now comparable to open surgery," said Shalhav, who has been performing laparoscopic prostatectomies for about two years, "but it has not yet become common. Most surgeons found it technically challenging and physically exhausting."

In standard laparoscopy, surgeons use long, slender instruments inserted through small holes and manipulated outside the body to isolate the prostate and remove it. The process can be slow, painstaking, awkward and uncomfortable for the surgeon.

"The operation is hard to learn, hard to perform and hard to teach," said Shalhav. "Your movements are reversed by the instruments, so in the beginning you have to think twice about each action, plus you are looking away from the patient and at a two-dimensional monitor."

The $1.2 million robotic system retains the benefits for the patient of laparoscopic surgery and solves some of the problems for the surgeon.

Instead of standing for hours with arms raised above the patient, the surgeon sits at a nearby console that provides a magnified, three-dimensional image. His wrists and hands are connected to glove-like sensors, which guide the tools on the robot's arms.

Those tools have more degrees of freedom than standard laparoscopic instruments, allowing the surgeon to cut, sew, cauterize, suction and remove tissue with considerable precision. The computer-controlled system can even reduce a surgeon's minute tremors.

The robot also provides excellent visualization of the surgical field, said Shalhav. The surgeon sees a magnified view. Twin cameras restore depth perception, which is lost in standard laparoscopy. Plus, there is much less bleeding than in traditional open surgery.

There are trade-offs, however. Most important is the loss of tactile sensation. "You can't feel any resistance," said Shalhav. "You can't even feel how tight your knots are. You have to rely on what you see and your experience."

Urologists at the University began performing robotic prostatectomies in February and now do about one a week, a number that is steadily increasing, but is still fewer than the four to six open prostatectomies performed at the hospital each week.

But the balance between open and robotic surgery could change quickly, urologists suspect. "This is remarkable technology," said Charles Brendler, M.D., professor of surgery and section chief of urology at the University of Chicago.

One of the originators of 'nerve-sparing' surgery, now the standard operation for prostate cancer, Brendler has performed more than 2,000 open procedures with one of the country's best records for tumor control and minimal side effects. He is now learning to perform this operation on the robot. "Otherwise," he said, only half joking, "this could be the end for me."

Up to now, robotic surgery has been confined to rare or unusual procedures. Although nearly 150 surgical robots have been placed in hospitals, most centers use them sparingly. Prostate surgery could be the first common procedure taken over by this approach.

There will be nearly 221,000 new cases of prostate cancer diagnosed in 2003, according to the American Cancer Society, and almost half of those men will chose surgical removal of he prostate.

At the University of Chicago Hospitals, the da Vinci Surgical System is also used for several other urologic applications, such as total or partial kidney removal, some general surgery, including gallbladder removal, and several cardiac and thoracic applications, including thymectomy, atrial septal defect closure, mitral valve repair, vascular ring division and patent ductus arteriosus ligation.